Grenfell – Are firefighters to blame? Understanding human error

We cannot allow firefighters on the ground to be blamed for actions whilst those with accountability at senior levels in the fire brigade, government and contracting firms ‘seek refuge in a judicial cocoon’.

A culture of blame can develop because it is often easier, cheaper, and more emotionally satisfying to hold an individual responsible for an accident than to acknowledge more fundamental problems in an organisation.

These may be more problematic, requiring resources, and more work. A culture of blame prevents the identification of other underlying causes.

James Reason, human error, 1990

We live in a world obsessed with blame. Whilst understandable regarding Grenfell, this obsession inhibits learning. Shifting from looking at who to blame to understanding who is accountable helps uncover deeper issues. Blame tends to be personal and emotive. Exploring where, how and why people failed to fulfil on their accountabilities reveals systemic issues and enables learning.

On Monday 11 February Chanel 4 Dispatches aired a program titled: Grenfell: Did the Fire Brigade Fail?

Reactions both before and after ranged from outrage that it was being aired coupled with a fierce defence of the bravery of the firefighters on the night, through to those advocating that we not shy away from engaging in tough questions in the interests of learning and preventing such events happening again.

As examples. Prior to the airing of Dispatches Karim Mussilhy who lost his uncle in the fire released a video making an impassioned plea that we not shy away from asking tough questions. And, the Emergency Service News issued an equally impassioned plea to remember what firefighters faced on the night.

I was torn by both sides. I’m fiercely defensive of the firefighters on the ground that night and equally committed that we hold the right people to account for what happened that night.

James Reason’s work on Human Error may be useful in helping navigate the complexity and tensions that the Dispatches program surfaced. It can help us move away from looking at who to blame to exploring where accountability lies and why people and organisations failed to fulfil on their accountabilities. This will reveal the deeper systemic issues that we intuitively know are at the heart of the Grenfell Fire.

Reason’s interest in human error was piqued with the Chernobyl Nuclear disaster (April 1986) which was largely due to human actions. He developed a way of categorising unsafe acts. This is sometimes referred to as a ‘Just Culture’ Framework. It provides a useful tool for assessing individual versus organisational accountability and can enable a shift away from emotive and simplistic blame narratives.

Events such as Grenfell are often triggered or escalated by human actions. Whilst never this simple in reality, these can be viewed in relation to adherence to policies and procedures. (This rests on the assumption that following policies and procedures is always a safe act which is questionable but that is a topic for another post)

There are three types of Unsafe Acts.

  • Errors where there is neither the intent to deviate from procedure nor to cause harm.
  • Violations where there is the intent to deviate from procedure but there is not an intent to cause harm.
  • Malicious Acts where actions are taken with the intent of harm.

Errors can further be classified as either Mistakes or Lapses.

  • Mistakes are ‘informational’ in nature, for example mistakenly thinking that you understand the procedure and doing what you think is correct when in fact it is not.
  • Lapses are ‘attentional’ in nature, for example you know what the correct procedure is but are distracted and make an error.

Violations can be classified as Routine, situational or optimising.

  • Routine violations are cultural in nature, it is the standard way of operating. This could, for example, be due to procedures being written that are not practical to follow. This is often the case where procedures are written by technical experts who do not understand the nature of work as practiced.
  • Situational violations occur when operating outside of the operating envelope or conditions that the procedures written for. The situation itself is calling for violation. This is most common during emergencies or unforeseen events.
  • Optimising violations occur when there is a perception that the violation will be beneficial in some way. Typically saving the individual or organisation either time or money. The benefit could be for the individual e.g. leaving work sooner. Or, for the organisation e.g. reducing time spent on a task to adhere to a tight schedule.

Overlaying individual versus organisational accountability onto this framework can help move beyond simplistic blame narratives and enable apportioning accountability where it belongs. This can lead to appropriate corrective actions, learning and change. For example for a mistake, the appropriate response is likely to be in the domain of training. Whereas, for a malicious act, disciplinary action including dismissal may well be appropriate.

I find Sydney Dekker’s concept ‘the context-dependent nature of action’ helpful. Very simply, our actions always make sense to us given the context we are operating in. To judge actions with the benefit of hindsight provides little valuable insight or access to learning. We need to ‘get in the tunnel’ and understand why it made sense for people to take the actions they did. I find this notion useful when inquiring into where accountability lies.

The view that we should blame individuals for errors (mistakes or lapses) is flawed. Say, for the sake of argument, that an individual firefighter made an error on the 14th June 2017. Even if this led to harmful unintended consequences, they are not personally to blame. Rather this would indicate that the system, processes and procedures are insufficiently resilient to deal with human error. This is an organisational issue and accountability would rest with those at senior levels who designed, implement and reviewed the system NOT the individual firefighter who made the error.

Relying on the lack of human error to keep people safe is a fundamentally flawed approach. We need to build systems that keep us safe that are sufficiently resilient to error.

This is particularly relevant with regards lapses at Grenfell. The conditions faced by the firefighters (both psychological and physical) would have increased the likelihood of lapses and poor decisions. They cannot be blamed for this.

Likewise you cannot blame individual firefighters for routine violations. These are cultural in nature and accountability rests with the senior leadership who hold responsibility for creating the culture of the organisation.

Evidence heard during the Inquiry would suggest that certain procedures were routinely violated. These violations may have contributed to the devastating consequences at Grenfell. However, the firefighters on the ground cannot be held accountable for this.

The fact that the procedure exists cannot be used to lay blame on individuals who in their normal operations would routinely ignore or violate this procedure. They were acting as they would normally act. That in this instance there were negative consequences cannot override that these actions were normally viewed as acceptable.

The senior management is accountable for enabling a culture where routine violations were acceptable.

Accountability for optimising violations is context dependent. If done for purely personal reasons in a culture that enables speaking up about concerns and issues, accountability would tend to lie with the individual. In situations where there is a perception that meeting other organisational objectives (such as budget/schedule pressures) justifies violating procedures, accountability would tend to rest with the senior leadership of the organisation

Finally, and perhaps most relevant to Grenfell, when you are operating in a situation that is beyond the envelope that the procedures were designed for, you are in the position of making choices you should never have to make and should not be held culpable for them. You may well make bad decisions but you will undoubtedly be doing your best in the circumstances you are in. Some of the choices you make will have positive impacts and some not. Accountability for situational violations needs to rest with those that either failed to predict the situation or those that created it.

At Grenfell there was a failure by the senior leadership of the Fire Brigade to predict and mitigate such an event. Whilst unprecedented it was not unpredictable. We need to understand how and why this failure occurred.

And finally, the refurbishment at Grenfell turned what was a relatively safe building into an unsafe one that according to expert witness Dr. Barbara Lane should never have been inhabited. We need to unpick and unravel the accountability failings that led to this. This must include the role of local and central government, regulators and contractors.

To illustrate my point.

In 1998 there was a catastrophic accident at the Esso Longford gas plant. Andrew Hopkins seminal account ‘Lessons from Longford’ describes how two workers were killed and eight injured. Gas supplies to the state of Victoria were affected for 2 weeks. The company blamed one of the workers who was on duty on the day of the explosion. A subsequent Royal Commission cleared the worker of any negligence or wrong doing and found Esso fully responsible for the accident. After being cleared, this is what he had to say:

While I’m not facing a lifetime of corrective surgery to mitigate disfigurement, I can’t work in a place where I once thought I would spend the next 27 years of my life. I cannot doff my hardhat to a company that blamed me for the deaths of two of my workmates, the burning of five others, the destruction of half a billion dollars of gas plant, and wish them well. I cannot respect a company that would gladly have me face the tearful, bewildered stare of a workmate’s bereaved family, while the directors of that company seek refuge in the judicial cocoon of their legal advice’

Hopkins, A, 2000, Lessons from Longford.

We cannot allow firefighters to be blamed for actions whilst those with accountability at senior levels in the fire brigade, government and contracting firms ‘seek refuge in a judicial cocoon’.

Gill Kernick, February, 2019, All rights reserved

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